The psychobiology of PTSD: coping with trauma
Introduction
Posttraumatic stress disorder (PTSD) is a relatively common psychiatric disorder, with an overall lifetime prevalence of about seven to twelve percent in the general US population (e.g. Kessler et al., 1995). More specifically, five to six percent of men and ten to twelve percent of women suffer from PTSD at some point in their lives, making it the fourth most common psychiatric disorder (Breslau et al., 1991, Resnick et al., 1993, Kessler et al., 1995). In patients with PTSD, studies have shown alterations in brain structures and functions, dysregulation in the neuroendocrine system, psychophysiological abnormalities as well as increased somatic symptoms and illnesses (Rasmusson and Friedman, 2002, Sala et al., 2004).
There is clear evidence that not every adult copes with potential trauma in the same way (Aldwin and Yancura, 2004). Research has indicated that most of individuals exposed to trauma do not develop PTSD, depression or other psychiatric or physical disorders (Kessler et al., 1995). After trauma exposure, about 10% of people are dysregulated in such a way that they develop PTSD (Breslau et al., 1998). How can we explain why only some people show neuroendocrine dysregulation due to exposure to trauma and develop (different types of) psychopathology but not others? The aim of this article is to describe the role that cognitive appraisal mechanisms and coping processes may play in determining outcome through their effects on neuroendocrine stress systems. In the stress literature psychological processes and behavioral patterns have been linked to neuroendocrine findings, identifying appraisal and coping as critical mediators of this link (Lazarus, 1966, Olff et al., 1993, Ursin and Olff, 1993, McEwen, 1998, Biondi and Picardi, 1999, Olff, 1999, Ursin and Eriksen, 2004). However, links between neuroendocrine stress response and cognitive appraisal mechanisms and coping processes have rarely been established in the context of traumatic stressors (Spaccarelli, 1994, Aldwin and Yancura, 2004, Olff et al., 2005). Clearly, examining the interrelationships among trauma, appraisal and coping processes, neuroendocrine stress responses, and mental health outcomes may provide important implications for psychosocial and pharmacological interventions designed to alleviate posttrauma symptoms.
Section snippets
Trauma, PTSD, and neuroendocrine dysregulation
Trauma exposure is a major risk factor for PTSD and major depressive disorder (Yehuda, 1997, Ehlert et al., 2001, Yehuda, 2002, Yehuda et al., 2004, Shea et al., 2005). It has been suggested that dysregulation of the HPA axis may be the basis for a link between trauma exposure and subsequent psychiatric disorder, because this axis plays a crucial role in the adaptive response to stress via homeostatic mechanisms. Considerable evidence shows a link between neuroendocrine dysregulation and
Cognitive models of PTSD
Several trauma theorists suggest that cognitive factors have critical impact on the trauma response, particularly in the persistence of PTSD through negative beliefs and appraisals of ongoing threat (Foa et al., 1989, Ehlers and Steil, 1995). For example, central in cognitive models of PTSD is the assumption that perception of a stressful event as a threat may be at least as important as trauma severity and variation in pre-trauma experience in the development and maintenance of PTSD (
Cognitive appraisal of the traumatic event
Epidemiological studies of PTSD prevalence showed that compared to subjective characteristics, the objective characteristics of events were far less sufficient predictors of this condition, particularly of the chronic subtype of PTSD (Ozer et al., 2003). Subjective appraisals of events including perceptions of loss, threat, harm and of controllability, do explain divergent results about the risk for PTSD. For instance, it may explain why someone develops PTSD after stressful, but seemingly
Coping with trauma
Generally, humans react with distinct coping strategies to different types of stress. Active coping strategies (e.g. confrontation, fight, escape) are usually elicited if the stressor or threat is controllable or escapable. Passive coping strategies (e.g. immobility, disengagement) are evoked if the stressor is uncontrollable or inescapable. Interestingly, recent anatomical studies indicate that different neural circuits mediate active and passive emotional coping strategies (e.g. Bandler et
Cognitive appraisal and neuroendocrine stress responses
The magnitude of the neuroendocrine stress response is mediated by stress appraisal, i.e. depends on whether the stressor is appraised as threatening (possibility of damage/harm) or as challenging (opportunity for gain). Psychobiological make-up and personality traits may influence whether a stressor is appraised as threatening or challenging, and, thereby, the physiological reaction to a stressful event or situation. For instance, it has been shown that people with an internal locus of control
Coping and neuroendocrine stress responses
In the traumatic stress literature only a few studies were found examining associations between coping and physiological parameters. An association between repressive coping strategy and affective-autonomic response discrepancy (low negative affect and elevated autonomic reactivity) has been reported among females with documented histories of childhood sexual abuse (Bonanno et al., 2003). Furthermore, among PTSD inpatients an association has been reported between lower cortisol levels and
Concluding remarks
The literature shows that cognitive appraisal and coping are of importance in adaptive psychological and biological responses to trauma. Cognitive appraisal, the subjective interpretation of the trauma, is crucial in starting the cascade of psychobiological responses to trauma. Virtually by DSM IV definition a traumatic event is evaluated as a threat (DSM IV; APA, 2001). A threat appraisal of a traumatic event or situation is followed by an acute stress response that involves both emotional,
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